Utilization Management Program

The Medicare Advantage Utilization Management (UM) Program is designed to promote quality, cost effective and medically appropriate services. The UM program uses a comprehensive approach by integrating key medical utilization management activities. Blue Cross and Blue Shield of Nebraska (BCBSNE) reviews and updates the UM program annually. 

The primary goals of the Medicare Advantage UM Program are to: 

• Achieve effective, high-quality outcomes that meet the expectations of members, purchasers and clinical health care professionals, by ensuring that medically necessary care is delivered in the appropriate setting at the time such service is needed. 
• Monitor effective and efficient medical and behavioral health utilization of services. 
• Provide a comprehensive UM Program to monitor member progress toward expected outcomes, resource use and efficient and effective transitions across the continuum of care.